Question 1

A 13-year-old boy presents for evaluation of fatigue during soccer practice. Urinalysis obtained during the visit shows a specific gravity of 1.010. He received IV fluids for mild dehydration. Which interpretation is most accurate?
 

A. Maximally concentrated urine
B. Severe dehydration
C. Isosthenuria similar to plasma
D. Definite diabetes insipidus
E. Nephrotic syndrome
 

Question 2

A 14-year-old girl undergoes CT imaging with intravenous contrast after a motor vehicle accident. A urinalysis later that day shows a specific gravity of 1.036 despite the patient appearing well hydrated. Which explanation best accounts for this finding?
 

A. Alkaline urine
B. Vitamin C ingestion
C. Radiocontrast exposure
D. Standing urine oxidation
E. Frequent voiding
 

Question 3

A 10-year-old boy with sickle cell disease presents for routine follow-up. His urinalysis repeatedly demonstrates specific gravity 1.005 despite limited fluid intake. Which interpretation is most appropriate?
 

A. He has a concentrating defect
B. He has evidence of glomerulonephritis
C. This is a normal finding
D. He has nephrotic syndrome
E. He likely has a UTI
 

Question 4

A 7-year-old girl presents with dysuria and fever. Urinalysis shows positive leukocyte esterase but negative nitrites. Which statement best describes leukocyte esterase testing?
 

A. Specific but not sensitive
B. Sensitive but not specific
C. Detects nitrate reduction
D. Detects WBC casts
E. Only positive in pyelonephritis
 

Question 5

A 9-year-old child has symptoms of urinary frequency. Urinalysis shows negative leukocyte esterase, but microscopy reveals numerous WBCs. The urine sample is extremely concentrated. Which explanation best accounts for this finding?
 

A. Vaginal contamination
B. Oxidizing contaminants
C. High urine specific gravity
D. Standing urine
E. Bacterial peroxidase
 

Question 6

A febrile 5-year-old presents with rash, conjunctival injection, and irritability. Urinalysis reveals pyuria, but urine culture remains negative. Which mechanism best explains the urine findings?
 

A. Nitrite contamination
B. Orthostatic proteinuria
C. Hemoglobinuria
D. Distal RTA
E. Sterile pyuria from systemic inflammation

 

Question 7

A 16-year-old athlete presents with dark urine after intense exercise. Urine dipstick shows 3+ blood, but microscopy shows no RBCs. What does the urine dipstick detect?
 

A. Intact RBCs only
B. Albumin
C. Heme pigments
D. Glomerular injury
E. Leukocyte enzymes
 

Question 8

A 17-year-old football player develops muscle pain and dark urine after preseason training. Urinalysis shows positive blood but no RBCs. What is the most likely cause?
 

A. False negative dipstick
B. Myoglobinuria
C. Orthostatic proteinuria
D. Hypercalciuria
E. Semen contamination
 

Question 9

A patient undergoing evaluation for hematuria repeatedly has negative blood dipstick tests despite suspected RBCs. He reports taking large amounts of vitamin supplements. Which substance most likely caused a false-negative test?
 

A. Myoglobin
B. Bacterial peroxidase
C. Vitamin C
D. Hemoglobin
E. Nitrites

 

Question 10

A pediatric resident reviews a urinalysis showing 2+ protein on dipstick. Which type of protein is primarily detected by urine dipstick?
 

A. All proteins equally
B. Albumin
C. Light chains
D. Tubular proteins
E. Globulins

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Question 11

A 13-year-old boy is referred for asymptomatic proteinuria detected on school screening. His first-morning urine UPC is normal. Blood pressure and creatinine are normal. What is the most likely diagnosis?
 

A. Minimal change disease
B. Orthostatic proteinuria
C. FSGS
D. Acute GN
E. Lupus nephritis
 

Question 12

Why is a first-morning urine sample recommended when evaluating proteinuria?
 

A. Detects infection
B. Eliminates need for UPC
C. Helps exclude orthostatic proteinuria
D. Detects tubular proteins
E. Prevents false nitrites
 

Question 13

Why is urine creatinine measured along with urine protein?
 

A. Diagnose hematuria
B. Estimate urine concentration
C. Identify RBC casts
D. Determine pH
E. Detect glucose
 

Question 14

A 6-year-old child presents with periorbital edema. UPC ratio is 3.0 mg/mg, albumin is 2.0 g/dL, and cholesterol is elevated. Which syndrome best explains these findings?
 

A. Orthostatic proteinuria
B. Hematuria syndrome
C. Distal RTA
D. UTI
E. Nephrotic syndrome

 

Question 15

Which UPC value represents nephrotic-range proteinuria?
 

A. ≥0.2 mg/mg
B. ≥0.5 mg/mg
C. ≥1 mg/mg
D. ≥2 mg/mg
E. ≥3 mg/mg
 

Question 16

A 5-year-old child presents with edema and heavy proteinuria but normal kidney function and complement levels. Which diagnosis is most likely?
 

A. FSGS
B. Minimal change disease
C. MPGN
D. IgA nephropathy
E. Lupus nephritis
 

Question 17

Why is kidney biopsy often deferred initially in typical pediatric nephrotic syndrome?
 

A. Minimal change disease is most likely
B. Biopsy unreliable
C. Contraindicated in nephrotic syndrome
D. Complement testing replaces biopsy
E. Proteinuria always resolves

Question 18

A child with nephrotic syndrome fails to respond to steroids after several weeks. What is the most appropriate next step?
 

A. Stop treatment
B. Kidney biopsy
C. Antibiotics
D. Dialysis
E. Vitamin therapy
 

Question 19

A teenager has persistent proteinuria with albumin-to-protein ratio (APR) of 0.7. Which type of proteinuria is most likely?
 

A. Glomerular
B. Tubular
C. Orthostatic
D. Overflow
E. Postrenal

Question 20

A patient with CKD has APR of 0.2, indicating albumin is a small fraction of total urinary protein. What pattern does this suggest?
 

A. Minimal change disease
B. Tubular proteinuria
C. Orthostatic proteinuria
D. Nephrotic syndrome
E. Glomerular proteinuria

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Question 21

A 10-year-old boy is found to have 5 RBCs/hpf on two separate urinalyses. He is asymptomatic with normal BP and kidney function. Which statement is correct?
 

A. Meets definition of hematuria
B. Excludes kidney disease
C. Indicates gross hematuria
D. Requires dialysis
E. Always causes anemia
 

Question 22

Which statement about gross hematuria is correct?
 

A. Less diagnostic than microscopic
B. GN usually painful
C. Often causes anemia
D. Higher likelihood of structural pathology
E. Always glomerular
 

Question 23

A 12-year-old boy presents with painful gross hematuria and dysuria. Which cause is most likely?
 

A. IgA nephropathy
B. PSGN
C. UTI or stones
D. Alport syndrome
E. Minimal change disease
 

Question 24

Hematuria appearing at the beginning of urination suggests which source?
 

A. Glomerular
B. Urethral
C. Renal
D. Tubular
E. Systemic
 

Question 25

Hematuria associated with blood clots suggests which source?
 

A. Glomerular
B. Lower urinary tract
C. Tubular
D. Systemic
E. Renal papillary
 

Question 26

A 9-year-old child presents with persistent microscopic hematuria and family history of hearing loss. Which diagnosis should be suspected?
 

A. IgA nephropathy
B. Distal RTA
C. Minimal change disease
D. Alport syndrome
E. UTI

 

Question 27

A child develops cola-colored urine and edema 10 days after streptococcal pharyngitis. Which diagnosis is most likely?
 

A. IgA nephropathy
B. PSGN
C. Minimal change disease
D. MPGN
E. ANCA vasculitis
 

Question 28

A teenager develops recurrent hematuria during respiratory infections with normal complement levels. Which diagnosis is most likely?
 

A. PSGN
B. Lupus nephritis
C. MPGN
D. IgA nephropathy
E. Anti-GBM disease

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Question 29

In PSGN, C3 complement levels usually normalize within:
 

A. 1 week
B. 2 weeks
C. 6–8 weeks
D. 6 months
E. Never
 

Question 30

A child with suspected PSGN has negative ASO but positive anti-DNase B. What does this indicate?
 

A. No infection
B. Anti-DNase B may still support recent streptococcal infection
C. IgA nephropathy
D. Lupus nephritis
E. ANCA vasculitis

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Question 31

A teenager presents with rapidly progressive kidney injury and hematuria. Kidney biopsy shows crescentic GN with little immune deposition. Which disease is most consistent?
 

A. Minimal change disease
B. ANCA vasculitis
C. MPGN
D. IgA nephropathy
E. Lupus nephritis

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Question 32

A patient develops hemoptysis and hematuria simultaneously. Anti-GBM antibodies are detected. Which structure is targeted?
 

A. Mesangium
B. GBM collagen IV
C. Podocyte slit diaphragm
D. Tubular basement membrane
E. Endothelium
 

Question 33

A child presents with palpable purpura, abdominal pain, and hematuria. Kidney biopsy shows IgA deposition. Which disease is most likely?
 

A. IgA nephropathy
B. HSP nephritis
C. Lupus nephritis
D. MPGN
E. ANCA vasculitis
 

Question 34

A patient presents with nephritic syndrome and persistently low complement levels. Biopsy shows complement deposition. Which disease is most consistent?
 

A. MPGN
B. IgA nephropathy
C. Minimal change disease
D. ANCA vasculitis
E. Anti-GBM disease
 

Question 35

A child with nephrotic syndrome relapses during steroid taper. Which classification applies?
 

A. Steroid-dependent NS
B. Frequently relapsing NS
C. Steroid resistant NS
D. Secondary NS
E. Congenital NS
 

Question 36

A child experiences four nephrotic syndrome relapses within one year. Which classification applies?
 

A. Steroid dependent
B. Frequently relapsing
C. Steroid resistant
D. Secondary
E. Congenital
 

Question 37

Which GN most commonly causes hematuria during infections?
 

A. PSGN
B. IgA nephropathy
C. MPGN
D. Anti-GBM
E. ANCA
 

Question 38

Which glomerular disease most commonly causes nephrotic syndrome in children?
 

A. MPGN
B. IgA nephropathy
C. Minimal change disease
D. ANCA vasculitis
E. Lupus nephritis
 

Question 39

Rapidly progressive GN with ANCA antibodies is most commonly associated with which pathology?
 

A. Immune complex GN
B. Pauci-immune crescentic GN
C. Membranous nephropathy
D. Minimal change disease
E. Diabetic nephropathy
 

Question 40

Which disease most commonly causes pulmonary-renal syndrome?
 

A. IgA nephropathy
B. MPGN
C. Anti-GBM disease
D. Minimal change disease
E. FSGS

Question 41

A 12-year-old boy develops cola-colored urine one day after the onset of a sore throat. He has no edema. Blood pressure is normal. Complement levels are normal.

Which diagnosis is most likely?
 

A. Post-streptococcal glomerulonephritis
B. IgA nephropathy
C. MPGN
D. Lupus nephritis
E. Minimal change disease

 

Question 42

Which statement best distinguishes IgA nephropathy from PSGN?

A. IgA nephropathy causes nephrotic syndrome
B. PSGN occurs within 24 hours of infection
C. IgA nephropathy typically occurs during infections, PSGN typically occurs after infections
D. Complement levels are always low in IgA nephropathy
E. IgA nephropathy causes pulmonary hemorrhage

 

Question 43

A 6-year-old child presents with edema and heavy proteinuria. Kidney function is normal. Complement levels are normal. The child responds rapidly to steroid therapy with resolution of proteinuria.

Which diagnosis is most likely?

A. Minimal change disease
B. FSGS
C. MPGN
D. IgA nephropathy
E. ANCA vasculitis
 

Question 44

A child with nephrotic syndrome initially responds to steroids but relapses whenever the steroid dose is tapered.

Which classification best describes this condition?

A. Steroid-resistant nephrotic syndrome
B. Steroid-dependent nephrotic syndrome
C. Frequently relapsing nephrotic syndrome
D. Secondary nephrotic syndrome
E. Congenital nephrotic syndrome
 

Question 45

A child with nephrotic syndrome experiences four relapses within one year despite successful steroid treatment of each episode.

Which classification best describes this pattern?
 

A. Steroid dependent nephrotic syndrome
B. Frequently relapsing nephrotic syndrome
C. Steroid resistant nephrotic syndrome
D. Secondary nephrotic syndrome
E. Congenital nephrotic syndrome
 

Answer Key 

Question 1. C. Isosthenuria similar to plasma Specific gravity ~1.010 reflects isosthenuria, meaning urine osmolality approximates plasma. This occurs when the kidney cannot concentrate or dilute urine, often seen in intrinsic renal disease.

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Question 2. C. Radiocontrast exposure. Radiocontrast is dense and osmotically active, which can artificially increase measured urine specific gravity even when the patient is well hydrated.

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Question 3. A Concentrating defect. Sickle cell disease commonly causes impaired concentrating ability due to medullary ischemia and papillary damage, resulting in hyposthenuria (low SG).

 

Question 4. B. Sensitive but not specific. Leukocyte esterase detects enzymes released by neutrophils. It is sensitive for inflammation but not specific for infection.

 

Question 5. C. High urine specific gravity. Very concentrated urine may produce false-negative leukocyte esterase results despite WBCs being present on microscopy.

 

Question 6. E. Sterile pyuria from systemic inflammation. Conditions such as Kawasaki disease or systemic inflammatory states can produce sterile pyuria, where WBCs are present without bacterial growth.

 

Question 7. C. Heme pigments. Urine dipstick for blood detects heme peroxidase activity, which can come from:

• RBCs

• Hemoglobin

• Myoglobin

 

Question 8. B. Myoglobinuria. Muscle injury (e.g., rhabdomyolysis) releases myoglobin, which causes positive blood dipstick without RBCs on microscopy.

 

Question 9. D. Vitamin C. Ascorbic acid (vitamin C) interferes with the dipstick oxidation reaction and may cause false-negative blood tests.

 

Question 10. B. Albumin. Urine dipstick protein detection primarily measures albumin, making it less sensitive for:

• tubular proteins

• light chains

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Question 11. B.Orthostatic proteinuria. Orthostatic proteinuria is common in adolescents and is characterized by:

• proteinuria when upright

• normal first-morning urine

 

Question 12. C. Helps exclude orthostatic proteinuria. First-morning urine is collected after overnight recumbency, eliminating the effect of upright posture on protein excretion.

 

Question 13. B. Estimate urine concentration. Urine creatinine allows calculation of protein-to-creatinine ratios, correcting for urine concentration.

 

Question 14. E. Nephrotic syndrome. Nephrotic syndrome is defined by:

• heavy proteinuria

• hypoalbuminemia

• edema

• hyperlipidemia

 

Question 15. D . ≥2 mg/mg. A UPC ≥2 mg/mg corresponds approximately to nephrotic-range proteinuria.

 

Question 16. B. Minimal change disease. Minimal change disease is the most common cause of nephrotic syndrome in children, particularly ages 1–10 years.

 

Question 17. A.Minimal change disease most likely. In typical pediatric nephrotic syndrome, the most likely diagnosis is minimal change disease, which is treated empirically with steroids without initial biopsy.

 

Question 18. B.  Kidney biopsy. Failure to respond to steroids suggests steroid-resistant nephrotic syndrome, warranting kidney biopsy to evaluate for diseases like FSGS.

 

Question 19. A.  Glomerular proteinuria. An albumin-to-protein ratio (APR) near 1 indicates most urinary protein is albumin, consistent with glomerular proteinuria.

 

Question 20. E. Tubular proteinuria. Low APR suggests protein is not predominantly albumin, indicating tubular proteinuria or non-albumin proteins.

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Question 21. A. Meets definition of hematuria. Hematuria is generally defined as ≥3–5 RBCs per high-power field on microscopy.

 

Question 22. D. Higher likelihood of structural pathology. Gross hematuria often reflects structural, infectious, or glomerular causes, and is more likely to yield a diagnosis.

 

Question 23. C. UTI or stones. Painful hematuria with dysuria is more suggestive of lower urinary tract causes, such as:

• UTI

• nephrolithiasis

 

Question 24. B. Urethral source. Hematuria appearing at the beginning of the urinary stream suggests urethral bleeding.

 

Question 25. B. Lower urinary tract. Clots usually originate from lower urinary tract bleeding because clots typically do not form in glomerular bleeding.

 

Question 26. D. Alport syndrome. Alport syndrome presents with:

• persistent microscopic hematuria

• family history of kidney disease

• sensorineural hearing loss

Question 27. B. PSGN. Post-streptococcal glomerulonephritis occurs 1–3 weeks after infection and presents with:

• hematuria

• edema

• hypertension

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Question 28. D. IgA nephropathy. IgA nephropathy causes synpharyngitic hematuria, meaning hematuria occurs during infections, not weeks afterward.

 

Question 29. C. 6–8 weeks. In PSGN, C3 complement levels usually normalize within 6–8 weeks.

Persistent hypocomplementemia suggests alternative diagnoses.

 

Question 30. B. Anti-DNase B supports recent infection. Both ASO and anti-DNase B detect recent streptococcal infection. Anti-DNase B may remain positive longer than ASO.

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Question 31. D. ANCA vasculitis. ANCA-associated vasculitis causes pauci-immune crescentic glomerulonephritis, characterized by minimal immune deposition on biopsy.

 

Question 32. B. GBM collagen IV. Anti-GBM antibodies target type IV collagen (α3 chain) in the glomerular basement membrane.

 

Question 33. B. HSP nephritis. Henoch–Schönlein purpura is a systemic IgA vasculitis causing:

• palpable purpura

• abdominal pain

• arthritis

• nephritis

 

Question 34. A.  MPGN. Membranoproliferative GN also classically shows double-contour (“tram-track”) GBM appearance.

 

Question 35. A. Steroid-dependent nephrotic syndrome. Steroid-dependent nephrotic syndrome occurs when relapse happens during steroid taper or shortly after discontinuation.

 

Question 36. B. Frequently relapsing nephrotic syndrome. Defined as:

• ≥2 relapses in 6 months, or

• ≥4 relapses in one year

 

Question 37. B. IgA nephropathy. IgA nephropathy commonly causes hematuria during mucosal infections.

 

Question 38. C. Minimal change disease. Minimal change disease accounts for ~80–90% of pediatric nephrotic syndrome.

 

Question 39. B. Pauci-immune crescentic GN. ANCA vasculitis produces rapidly progressive GN with crescent formation and minimal immune deposition.

 

Question 40. C. Anti-GBM disease. Anti-GBM disease can cause pulmonary-renal syndrome, with:

• hemoptysis

• hematuria

• rapidly progressive GN

 

Question 41. B (IgA nephropathy). Hematuria during infection is classic for IgA nephropathy.

 

Question 42. C

Key board distinction:

IgA = synpharyngitic (during infection)
PSGN = post-infectious
 

Question 43. A (Minimal change disease). Classic pediatric nephrotic syndrome with steroid responsiveness.

 

Question 44. B (Steroid-dependent NS). Definition: Relapse occurs when steroids are tapered or stopped
 

Question 45.  B.  (Frequently relapsing NS) Definition: ≥2 relapses in 6 months OR ≥4 in one year

I

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